A nurse attempted to cover up her mistake after giving a six-week-old baby the wrong vaccine.
Deputy Health and Disability Commissioner Rose Wall released a report on the 2019 incident today.
It states the baby was overdue for his six-week vaccinations and during a home visit, the nurse administered the wrong vaccine to the baby.
"Instead of the rotavirus vaccine, the nurse vaccinated the baby with Prevenar 13, a vaccine that is normally administered by injection for protection against pneumococcal disease," the report reads.
"This was in addition to the PCV10 vaccine (another vaccine used for the protection against pneumococcal disease) meaning that the baby was essentially given the same vaccination twice on this day, and missed out on his rotavirus vaccine."
The error was picked up a day later and the nurse was alerted to it.
However, the report says she never reported it, instead attempting to cover it up by making a second home visit to amend the records in the baby’s Well Child book.
"The nurse should have alerted the baby’s family to her mistake, and her failure to report it lead to a delay in the error being rectified," Wall said in her report.
"It also meant that the baby’s family were not alert to signs of possible reaction to the drug error in the young infant.
"Instead of owning up to her mistake, the nurse went to significant efforts in an attempt to cover up her error," she said.
In the summation, the Deputy Commissioner recommended the nurse undertake training on documentation and safe administration of medications, and provide the baby’s family with a written apology.
She also recommended that the Nursing Council of New Zealand consider whether a review of the nurse’s competence and any further action is warranted. The nurse was also referred to the Director of Proceedings.
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